Since the Ebola outbreak in the Democratic Republic of Congo began in the summer of 2018, there have been more than 3,039 confirmed cases of the disease and more than 2,013 deaths there as of mid-September 2019. It is the worst Ebola outbreak in history after the West African epidemic of 2014–2016, during which there were 28,652 cases and 11,325 deaths. All but a handful of the cases have occurred in eastern Congo, much of which is difficult to reach, with dense forests and poor roads. But this is also the first outbreak in an active conflict zone, and attacks on medical workers have hampered the efforts to contain it, as has distrust among Congolese of the government and of the methods and priorities of international aid agencies. The outbreak’s persistence has brought into sharp relief the shortcomings of the international response to Ebola, and to emerging disease threats more generally.
Ebola, a hemorrhagic fever virus that was discovered in Congo in 1976, has a terrifying reputation for extraordinary contagiousness and lethality: in the public imagination, those infected inevitably end up “bleeding to death from every orifice.” The film Outbreak (1995) reinforced that reputation: it depicted a thinly fictionalized airborne version of Ebola so dangerous that the army decides to bomb the California town to which it has spread, less to prevent continent-wide contagion than to protect its potential as a biological weapon. A virus emerging from Africa and able to cause certain death by vascular meltdown seemed made for Hollywood. Yet until 2014, none of the twenty-odd outbreaks in remote parts of Congo, Uganda, South Sudan, Gabon, and Congo- Brazzaville had lasted longer than a few months or caused more than 280 deaths.
In 2014, as Ebola began to spread swiftly across Liberia and Sierra Leone, the West still seemed invulnerable to it. But that changed on August 2, 2014, when an American doctor infected with the virus was medevacked back to the US from Liberia. Three days later, a second infected aid worker was evacuated. American news stories raised alarms about Ebola “coming to our shores.” The World Health Organization (WHO) declared a Public Health Emergency of International Concern (PHEIC). The US Centers for Disease Control predicted that 1.4 million people would be infected in West Africa; its failure to prevent the arrival in the US of the first traveler infected with the disease, a Liberian man diagnosed on September 30 in Dallas, did nothing to reassure the public. Two nurses at the Texas Health Presbyterian Hospital, where he was being treated, then became infected—the first transmission of Ebola outside Africa. Soon Amazon was selling Ebola survival kits complete with Hazmat suits, body bags, bleach, and lots of duct tape. Serious survivalists planned for months of isolation. The US government sent the 101st Airborne Division to Liberia to help fight the outbreak. Thirty governments stopped flights to the region.
In the end, Ebola remained largely confined to West Africa. Only three people were infected outside Africa—two in the United States and one in Spain. Of the twenty-seven cases treated outside Africa, five deaths occurred among those treated in either the US or Europe. Yet the panic suggested how sheltered from epidemic diseases the West had become.
Since then, considerable attention has been paid to improving the international response to Ebola outbreaks, which has been aided by biomedical innovations, including two vaccines and four experimental treatments. When Ebola broke out in Équateur province in western Congo on May 8, 2018, it was brought under control by July 25, with a total of fifty-four cases and thirty-three deaths.
Eleven hundred miles east, sporadic cases of viral hemorrhagic fever in Mangina, a remote village in Congo’s North Kivu province, went unnoticed. Although probable cases dated back to April 30, 2018, it was not until mid-July, when Ebola started to spread within health centers, that reports of it began circulating. By the time the new outbreak had been lab-confirmed in the Congolese capital of Kinshasa (on the other side of the country) on July 28, the disease had already spread north to neighboring Ituri province and begun moving southeast within North Kivu. On August 1, as the Ministry of Health declared Congo’s tenth outbreak, Ebola reached the North Kivu city of Beni.
The recently contained outbreak in western Congo meant that a vaccine supply, cold chains (the system set up to keep vaccines refrigerated and viable until they are administered), and trained medical teams were available, and protocols had already been developed and approved. The international response was reactivated, and a vaccination campaign began a week later. Experimental treatment for patients with lab-confirmed disease was available within days.
While transmission in Mangina and in southern Ituri province was controlled by late August 2018, achieving control in Beni was more difficult. By September, the virus had spread further south to Butembo and Katwa, major commercial hubs with close ties to Uganda, as well as to neighboring towns and distant villages. Yet by late December, the fatality rate for those infected had dropped to 57 percent, and community deaths (those occurring outside of an Ebola treatment center, whether at home or in another health facility) were down to about 30 percent of the overall death toll. By February 18, 2019, Beni had gone twenty-one days (the upper limit of the incubation period) without a case, and transmission rates in Katwa and Butembo were declining.
Then two lethal attacks in late February by Mai Mai—local armed groups originally formed to defend against incursions by Rwandan forces or Congolese rebels affiliated with Rwanda—on Ebola treatment centers in North Kivu run by Médicins sans Frontières (MSF) forced the organization to evacuate. After a third attack in March, patients fled and did not return. On June 11 Ebola appeared briefly in Uganda, carried by a family that had just returned from a funeral in eastern Congo. A month later, a pastor on his way home from a mission in Butembo became the first case in Goma, the provincial capital of North Kivu and the biggest city in eastern Congo. In August the disease spread further south to Mwenga, in South Kivu, and an infected Congolese girl traveling with her mother to seek medical care in Uganda was identified at the border and transferred to Bwera Hospital, where she later died.
One year later, the limits of international efforts to contain the virus have become apparent. On the one hand, more than 214,000 people have been vaccinated and 91 million travelers screened, and apart from the few cases in Uganda the outbreak has not spread—yet—beyond eastern Congo, despite proximity to porous international borders. On the other hand, the outbreak continues. On July 17, 2019, the WHO declared a PHEIC in Congo.
Ebola is a zoonosis: a virus that jumps from animals to humans, in this case probably as a result of eating bushmeat—a term covering bats, monkeys, rats, and duikers—although that is uncertain. The virus has been found in bats, but it is not known if they are Ebola’s natural host, the exact “reservoir species” that harbors the virus. Unlike airborne pathogens with epidemic potential, the Ebola virus is transmitted by contact with patients or their bodily fluids. A person infected with it isn’t contagious until symptoms develop, and contagiousness increases as the disease progresses, peaking at the point of death and persisting for several days afterward.
Upon entering the body, Ebola begins by killing immune cells before proceeding to major organs, eventually causing multi-organ dysfunction. Like many other viruses, its symptoms are fever, headache, diarrhea, vomiting, and muscle and joint pains. Death usually occurs not from uncontrolled hemorrhaging but from hypovolemic shock (when severe blood or fluid loss means the heart cannot pump sufficient blood to vital organs) owing to the extreme dehydration caused by vomiting and diarrhea. The fatality rate can vary widely: in the 1976 outbreak it reached 88 percent, in Sierra Leone in 2016 it was as low as 28 percent.
Ebola’s reproductive value (R0) is 2—on average one person infects two others (for comparison, the R0 for measles is 12–18, for SARS and HIV, 4). Most transmission occurs during the provision of care. Medical staff and caregivers are most at risk. In hospitals, all patients must be isolated and cared for by personnel wearing protective clothing and using infection prevention and control measures. During an outbreak, all deaths must be considered possible Ebola cases unless proven otherwise. Safe burials are crucial to cut chains of transmission. This means all corpses must be stripped and sprayed with chlorine, wrapped in plastic, and buried under supervision. All houses where deaths occur must be disinfected.
Earlier treatment of Ebola improves the chances of survival and is a better way to stop transmission. Because the disease is less contagious at earlier stages, fewer people are exposed, which facilitates identifying and tracking down the contacts of those infected so they can be tested for it. Once found, contacts can be given the highly effective new vaccine, which not only prevents disease in 97.5 percent of those exposed but also brings the fatality rate down to 0–16 percent in those who do develop the disease.
Unfortunately, the risk of acquiring Ebola in hospitals makes it difficult for health workers to convince Congolese to come to them for testing, let alone treatment. People who have been in contact with infected patients may hide from surveillance teams. The fact that more than 200,000 vaccinations have been administered is proof of a certain level of engagement with communities. However, the restricted strategy of ring vaccination—vaccinating only the contacts of infected people, as well as the contacts of their contacts—lends itself to speculation about preferential vaccination and is confusing for communities that are used to more traditional population-wide vaccination. A doubling in the proportion of community deaths from 28 percent in February to nearly 60 percent in July is an indicator of this growing distrust, as is a rise in the fatality rate over the same time period from 57 percent to 67 percent. In early August analysis of four experimental drugs showed that two were extremely effective in reducing mortality, though only if given in the early stages of the disease; these drugs are now available to all patients, but the overall fatality rate is unchanged.
The biggest impediment to containing Ebola in Congo is not its contagiousness, but suspicion of the state and of aid personnel. Since 2000, international agencies have spent more than $9 billion on aid in the country, with a further $1.65 billion sought for the humanitarian response in 2019. While some aid agencies manage to provide valuable services, they are also seen by many Congolese as having questionable ethics. Despite the presence since 1999 of MONUSCO, the UN’s largest peacekeeping force, Congolese are routinely subjected to extortion and violence by armed groups—the fallout of regional wars sparked by the genocide in Rwanda—who compete for control of the illegal transborder trade in gold, timber, ivory, charcoal, and drugs. In Beni, systemic human rights abuses by the Allied Democratic Forces (ADF), founded by Ugandan exiles in 2003, highlight the weakness of the 20,000 MONUSCO troops. Since April 1, 2017, the ADF has seized at least 453 teenagers to serve as child soldiers and killed 545 civilians in a series of violent massacres.
And despite enormous needs, little evidence of international humanitarian assistance can be found in eastern Congo outside of Goma. Most of the population lack clean water and electricity, let alone basic health care. An ongoing measles outbreak and four distinct circulating strains of vaccine-derived poliovirus reflect the critically low vaccination coverage of preventable childhood illnesses. Malaria, the leading cause of death, kills an estimated 50,000 each year. Other deadly outbreaks include cholera, yellow fever, and monkey pox.
Communities in North Kivu and Ituri had no experience with Ebola, which had never before been reported in this part of Congo. When a highly visible and well-resourced international response (known as the “riposte”) showed up in the summer of 2018, directed against a disease that few had ever heard of, the region’s ingrained distrust quickly extended to it. Unfamiliar technologies, such as heat-sensor thermometers—a pistol-shaped device that measures body temperature when pointed at a person’s head—lent themselves to rumors that people were being injected with the virus or even brainwashed.
Other residents perceived the Ebola response as benefiting the rich and powerful. The arrival of vaccinators from Guinea to train locals and of medical teams with recent experience in Équateur was readily mistaken for a gravy train of people from Kinshasa coming to take up well-paid positions in lieu of local employees. The erection of health checkpoints on international and provincial borders slowed down travel and trade, increased border fees threefold, and encouraged extortion.
Then the international responders aggravated the community’s distrust by interpreting reluctance to follow rules about safe burials and patient isolation as a lack of understanding of public health that required reeducation. In fact, the reluctance reflected an understandable lack of enthusiasm for practices that required total separation from loved ones during their illness, denial of human touch at the point of death, and the abandonment of traditional funeral rites, which are of central importance to social and cultural life.
Rote messages about hand-washing delivered to communities without consistent access to water were annoying. Heavy-handed warnings about bats and chimps as possible sources of infection accompanied by pictures of people bleeding from their eyeballs backfired. Vaccination clinics became props for international politicians arriving in SUVs, seemingly more interested in selfies than in listening to locals. Inattention to community feedback and lack of interest by responders in the quotidian health concerns that kill in larger numbers than Ebola underscored the perception that international concern was self-interested. “Riposte” became a toxic word. Fatigue, even hatred, set in. Communities experienced in evading armed groups had no trouble hiding from Ebola surveillance teams.
Against a backdrop of presidential elections, the free health care provided by the official Ebola response was interpreted as political opportunism and shunned. In any case, many Congolese considered state-funded clinics inferior to private clinics and traditional healing centers. In Beni, the majority of private practitioners were unvaccinated and lacked experience with Ebola, and the 250-odd clinics across the city had no adequate infection control.
In October 2018, matters were made worse by a malaria outbreak. Since the early symptoms of malaria are similar to those of Ebola, health care workers could not easily tell the difference. Meanwhile, the widespread lack of rapid tests for malaria (which can deliver a diagnosis in two minutes) meant that providers were faced with hundreds of possible Ebola infections, all of which had to be tested, and it takes a minimum of twenty-four hours for those results to be confirmed by a lab. This slowed down the response, overwhelmed clinics, and drove hospital-acquired transmission. In a desperate attempt to relieve pressure on the health system, WHO organized the distribution of 35,000 bed nets and large quantities of antimalarial drugs, which helped to reduce the community’s hostility.
Around this time, the Congolese minister of health requested the help of the king of Congo, part of a monarchical tradition in the region that exists parallel to the state. In an area distrustful of government and outsiders, the king enjoys enduring allegiance. He arrived, mobilized traditional leaders, and met with community members and armed groups. In Beni, Congo’s most violent city, the ADF and other armed groups stepped aside to allow the riposte to proceed. Within six weeks, transmission rates appeared to be under control.
In December, however, the government of President Joseph Kabila cited the presence of Ebola to justify excluding affected areas from the highly contested vote for his successor. That aggravated tensions because Beni and Butembo, the two epicenters of the outbreak, were considered opposition strongholds. It also ignored the advice of Tedros Adhanom Ghebreyesus, the director-general of WHO, who had emphasized that polling booths are valuable venues for public health messaging. Instead, the violence that accompanied the suspended elections led to vandalization of an MSF treatment center and marked the start of an increasingly violent year. Since January, there have been more than 250 recorded attacks on health facilities and workers in the Ebola zone, with six deaths. The result has been a catastrophic rise in transmission.
Too often, policymakers approach outbreak response as an exercise in fighting fires rather than addressing underlying systemic factors. After the 2014–2016 Ebola epidemic in West Africa, a UN High-Level Panel on Global Health Crises focused on outbreaks that might leap to the West, such as Ebola, pandemic flu, Lassa, and Nipah. Malaria, TB, HIV, and cholera—diseases that take millions of lives each year in the Global South—were excluded, on the pretext that they had already spread across the globe and thus needed a different containment strategy. Yet prioritizing Ebola in West Africa came at considerable human cost—during 2014 an estimated 3.5 million cases of malaria went untreated, leading to 10,900 additional deaths, three times as many as from Ebola. In just Sierra Leone, 3,600 women and newborns—a conservative estimate—died in 2014 from the lack of life-saving health services. And although war is a well-known incubator of epidemic threats, the panel (which I briefed) did not consider how outbreaks in areas of armed conflict could be managed or the escalating trend of attacks on health care workers and facilities, which compound the risk of emerging threats.
Western governments have largely prioritized research, with a focus on vaccine development. In addition to Ebola, the Zika, Lassa, and Nipah viruses have been targeted. However, such vaccines do not promise much profit for pharmaceutical companies, since the people in outbreak zones generally cannot pay for them. As a result, companies must donate vaccines or donors must buy them on behalf of others. This raises concerns about sustaining research and development of vaccines, and the interest of the pharmaceutical industry in producing them. In 2017 development of Merck’s and Janssen’s Ebola vaccines proceeded only after an $84 million gift from the US government. Even then, the quantities produced were limited, and we are now confronting vaccine shortages. The biotech company Moderna is developing a Zika vaccine and could develop more vaccines for pandemic readiness, but is lacking the capital to do so.
People in the Global South see through this selectivity. This undermines the international community’s ability to intervene against the diseases that most concern the West. For reasons of effectiveness if not simple fairness, a more comprehensive approach is needed. On July 22, Congo’s minister of health resigned, citing misguided international preoccupation with using a second vaccine despite the very real risk of causing confusion among those living in affected areas, as well as his government’s focus on Ebola as an emergency rather than as symptomatic of Congo’s abysmal public health system.
During the West African epidemic, the lack of vaccines and treatment options meant control of the disease depended on community trust to secure compliance with contact-tracing and safe burials as well as early treatment. The color of body bags used today tells a story of successful community engagement. At first, the body bags for Ebola fatalities were black, making them seem no different from garbage bags. Margaret Chan, then the WHO director-general, reminded people that shrouds are normally white. Changing the color meant people were much more likely to comply with safe-burial instructions.
Despite multiple postmortems of the West African epidemic that stressed the necessity of including social scientists in future responses, no research or investment in community engagement followed. Even the best biomedical solutions need social support, as the anti-vax movement in the United States illustrates. The problem only increases as we move from time-tested vaccines to new and experimental ones, such as the Ebola vaccine now being used in Congo.
Moreover, the single-disease approach to pandemic threats—and simultaneous exclusion of far more common diseases—is clinically counterproductive. Despite the scare posters for Ebola, patients rarely show up bleeding from their eyeballs—or from any other orifice. Instead, the symptoms of Ebola are shared by many other infectious diseases, of which malaria, measles, typhoid, and yellow fever especially concern the populations of places where emerging threats are likely. Failure to integrate at least malaria into an Ebola response delays diagnosis and increases the risk of transmission in hospitals. Conversely, including malaria gives people an incentive to seek early treatment, the single most effective way to stop the spread of Ebola.
Similarly, the debate that brewed for months about whether the WHO should declare a PHEIC for Congo’s Ebola outbreak reflects an agenda that prioritizes distant international fears over local needs, amplifying community distrust. That three prior PHEICs have been declared only when Western countries have felt threatened is not lost on the Congolese. A PHEIC encourages travel bans, movement restrictions, and border closures, despite WHO recommendations to the contrary. The economy in an impoverished region suffers. Barriers that are a proxy for disease containment are prioritized over individual livelihoods, children’s education, and the health needs and social networks of communities. In eastern Congo, an area where cross-border living is a way of life, at least 100,000 people commute daily between Congo and Uganda or Rwanda for work, school, shopping, family visits, weddings, funerals, church, and health care. Coercive measures are more likely to alienate communities than engage them—yet they are already being applied.
A public declaration is useful only if it yields a genuine change in the international response to threats like Ebola. We have the tools for global disease surveillance, rapid response, and biomedical solutions, but the greatest challenges to controlling any epidemic are social, not technical. Effective front-line surveillance and defenses in the Global South require investing in primary health care, school nurses, midwives, community health workers, and traditional healers. Ebola is certainly a serious concern, but a bigger concern is having a health system that addresses all of a community’s needs, from child health to heart disease, prenatal care to arthritis. The WHO has been pushing for this since the outbreak in western Congo ended in July 2018, trying to make the most of the emergency attention to Ebola to attract longer-term investment. It is not only the right thing to do but is also necessary for the Ebola response to succeed.
—September 25, 2019